Hip Arthroscopy: An Emerging Gold Standard

After reading your editorial,1Lubowitz J.H. Poehling G.G. Hip arthroscopy: An emerging gold standard.Arthroscopy. 2006; 22: 1257-1259Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar we are concerned that some readers may come away with the impression that the first choice for treating hip pathology amenable to joint preservation should be hip arthroscopy. Unlike the knee, where pure ligamentous/cartilage injury represents the main underlying pathology, in the hip it is just the opposite.2Wenger D.E. Kendall K.R. Miner M. Trousdale R.T. Acetabular labral tears rarely occur in the absence of bony abnormalities.Clin Orthop Relat Res. 2004; : 145-150Crossref PubMed Scopus (329) Google Scholar, 3Peelle M.W. Della Rocca G.J. Maloney W.J. Curry M.C. Clohisy J.C. Acetabular and femoral radiographic abnormalities associated with labral tears.Clin Orthop Relat Res. 2005; 441: 327-333Crossref PubMed Scopus (109) Google Scholar In the vast majority of cases, the primary pathology is a bony dysmorphism (dysplasia, femoroacetabular impingement) that subsequently leads to damage of the labral/chondral complex.4Beck M. Kalhor M. Leunig M. Ganz R. Hip morphology influences the pattern of damage to the acetabular cartilage: Femoroacetabular impingement as a cause of early osteoarthritis of the hip.J Bone Joint Surg Br. 2005; 87: 1012-1018Crossref PubMed Scopus (1427) Google Scholar, 5Leunig M. Podeszwa D. Beck M. Werlen S. Ganz R. Magnetic resonance arthrography of labral disorders in hips with dysplasia and impingement.Clin Orthop Relat Res. 2004; : 74-80Crossref PubMed Scopus (248) Google Scholar This is critical because these bony dysmorphisms represent known causes of hip arthritis6Murphy S.B. Ganz R. Muller M.E. The prognosis in untreated dysplasia of the hip A study of radiographic factors that predict the outcome.J Bone Joint Surg Am. 1995; 77: 985-989PubMed Google Scholar, 7Harris W.H. Etiology of osteoarthritis of the hip.Clin Orthop Relat Res. 1986; : 20-33PubMed Google Scholar, 8Ganz R. Parvizi J. Leunig M. Siebenrock K.A. Femoroacetabular impingement: A cause for osteoarthritis of the hip.Clin Orthop Relat Res. 2003; : 112-120PubMed Google Scholar and failure to recognize and treat these deformities can affect the outcome of surgical treatment and the survivorship of the native hip joint. Understanding and treating associated structural abnormalities of the hip must be emphasized and not forgotten in our enthusiasm for arthroscopic procedures, where osteotomies about the hip joint have a documented record of clinical success.9Millis M.B. Murphy S.B. Poss R. Osteotomies of the hip joint for the prevention and treatment of osteoarthritis.Instr Course Lect. 1996; 45: 209-226PubMed Google Scholar More simply stated: Is knee arthroscopy the gold standard to treat a varus deformity of the knee with minimal arthritic changes?We are encouraged by the evolution of hip arthroscopy in the treatment of the painful hip and support your desire to advance the applications of hip arthroscopy. However, some caution is necessary to avoid an uncontrolled expansion of arthroscopic surgery of the hip and to avoid repeating the phenomenon that occurred in general surgery, where there was an increase in the rate of cholecystectomies with the introduction of laparoscopic cholecystectomy. We strongly encourage those surgeons performing hip arthroscopy to carefully assess the pathomechanics and pathophysiology of symptomatic hips and to critically contemplate the appropriateness of hip arthroscopy, especially in the setting of underlying structural hip disease (acetabular dysplasia and nonfocal impingement disorders), which is best assessed with anteroposterior and cross-table lateral radiographs. After reading your editorial,1Lubowitz J.H. Poehling G.G. Hip arthroscopy: An emerging gold standard.Arthroscopy. 2006; 22: 1257-1259Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar we are concerned that some readers may come away with the impression that the first choice for treating hip pathology amenable to joint preservation should be hip arthroscopy. Unlike the knee, where pure ligamentous/cartilage injury represents the main underlying pathology, in the hip it is just the opposite.2Wenger D.E. Kendall K.R. Miner M. Trousdale R.T. Acetabular labral tears rarely occur in the absence of bony abnormalities.Clin Orthop Relat Res. 2004; : 145-150Crossref PubMed Scopus (329) Google Scholar, 3Peelle M.W. Della Rocca G.J. Maloney W.J. Curry M.C. Clohisy J.C. Acetabular and femoral radiographic abnormalities associated with labral tears.Clin Orthop Relat Res. 2005; 441: 327-333Crossref PubMed Scopus (109) Google Scholar In the vast majority of cases, the primary pathology is a bony dysmorphism (dysplasia, femoroacetabular impingement) that subsequently leads to damage of the labral/chondral complex.4Beck M. Kalhor M. Leunig M. Ganz R. Hip morphology influences the pattern of damage to the acetabular cartilage: Femoroacetabular impingement as a cause of early osteoarthritis of the hip.J Bone Joint Surg Br. 2005; 87: 1012-1018Crossref PubMed Scopus (1427) Google Scholar, 5Leunig M. Podeszwa D. Beck M. Werlen S. Ganz R. Magnetic resonance arthrography of labral disorders in hips with dysplasia and impingement.Clin Orthop Relat Res. 2004; : 74-80Crossref PubMed Scopus (248) Google Scholar This is critical because these bony dysmorphisms represent known causes of hip arthritis6Murphy S.B. Ganz R. Muller M.E. The prognosis in untreated dysplasia of the hip A study of radiographic factors that predict the outcome.J Bone Joint Surg Am. 1995; 77: 985-989PubMed Google Scholar, 7Harris W.H. Etiology of osteoarthritis of the hip.Clin Orthop Relat Res. 1986; : 20-33PubMed Google Scholar, 8Ganz R. Parvizi J. Leunig M. Siebenrock K.A. Femoroacetabular impingement: A cause for osteoarthritis of the hip.Clin Orthop Relat Res. 2003; : 112-120PubMed Google Scholar and failure to recognize and treat these deformities can affect the outcome of surgical treatment and the survivorship of the native hip joint. Understanding and treating associated structural abnormalities of the hip must be emphasized and not forgotten in our enthusiasm for arthroscopic procedures, where osteotomies about the hip joint have a documented record of clinical success.9Millis M.B. Murphy S.B. Poss R. Osteotomies of the hip joint for the prevention and treatment of osteoarthritis.Instr Course Lect. 1996; 45: 209-226PubMed Google Scholar More simply stated: Is knee arthroscopy the gold standard to treat a varus deformity of the knee with minimal arthritic changes? We are encouraged by the evolution of hip arthroscopy in the treatment of the painful hip and support your desire to advance the applications of hip arthroscopy. However, some caution is necessary to avoid an uncontrolled expansion of arthroscopic surgery of the hip and to avoid repeating the phenomenon that occurred in general surgery, where there was an increase in the rate of cholecystectomies with the introduction of laparoscopic cholecystectomy. We strongly encourage those surgeons performing hip arthroscopy to carefully assess the pathomechanics and pathophysiology of symptomatic hips and to critically contemplate the appropriateness of hip arthroscopy, especially in the setting of underlying structural hip disease (acetabular dysplasia and nonfocal impingement disorders), which is best assessed with anteroposterior and cross-table lateral radiographs. Hip Arthroscopy: An Emerging Gold StandardArthroscopyVol. 22Issue 12PreviewAs the Arthroscopy Association of North America and Arthroscopy: The Journal of Arthroscopic and Related Surgery enjoy a third decade, the emergence of hip arthroscopy as a gold standard of treatment for diverse hip joint pathology reminds us of one of the joys of being arthroscopic surgeons. Specifically, we are reminded of the joy we derive from doing work where we continually experience and observe new technology and techniques as they evolve from experimental, to state of the art, to the gold standard of care. Full-Text PDF

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